Original Research Article S57

KNOWLEDGE, ATTITUDES AND PRACTICES REGARDING TO MALARIA AND HOME ENVIRONMENT PREVENTION AMONG POPULATION IN PALAW TOWNSHIP, TANINTHARYI REGION OF MYANMAR

Khaing Nyan Linn1, Nutta Taneepanichskul1, *, Saowanee Norkaew2

1 College of Public Health Sciences, Chulalongkorn University, Bangkok, 10330, Thailand 2 Faculty of Public Health, Thammasat University, Rangsit Campus, 12121, Thailand

ABSTRACT: Background: Malaria is still a priority public health problem in Myanmar. Socio-cultural, economic factors, housing conditions, knowledge, attitude, and practices of the community play an essential role in transmission and preventing malaria infection. Therefore, this study assessed association between knowledge, attitudes and practices levels among population in Palaw Township, Tanintharyi Region of Myanmar. Methods: A cross-sectional study method was conducted during June-July, 2016 to identify knowledge, attitude and practice regarding to malaria prevention among population in Palaw Township, Tanintharyi Region of Myanmar. Four hundred and thirty participants aged 18-64 years were participated in this study. A structure questionnaire was used to gather the data. Chi-square and Fisher’s exact test were used to determine the association between knowledge, attitude and practice. Results: The findings showed 50.7% of respondents had good knowledge; 16.3% had good attitude, while only 6.5% had good practice regarding malaria prevention. The study found strong significance association between knowledge about malaria and prevention practices (p<0.001). Good knowledge and good attitude were high; and prevention practice was moderate. Knowledge towards malaria causes, transmission, symptoms and home environment prevention were significantly associated with prevention practice. Susceptibility, threat, treatment and home environment prevention attitude were found an association with prevention practice (p<0.001). Conclusion: Health education program with direct interaction to community should be emphasized; and the correct knowledge about housing condition and housing structure to prevent malaria should be provided in order to improve the knowledge, attitude, and practice regarding malaria prevention.

Keywords: Knowledge, attitude, practices; Malaria; Home environment; Myanmar

DOI: 10.14456/jhr.2017.68 Received: November 2016; Accepted: May 2017

INTRODUCTION world's population of fifty percent lives in malaria Malaria is the infectious and tropical disease. risk area [1]. According to the World Malaria Report Malaria remains a major problem of global health 2014 in Myanmar, there were 37% of high with approximately 3.2 billion people; nearly transmission (> 1 case per 1000 population) and 23% of low transmission (0–1 cases per 1000 * Correspondence to: Nutta Taneepanichskul population) in 2013 [2]. It was a national concern in E-mail: [email protected] Myanmar; and it is a leading cause of morbidity and

Linn KN, Taneepanichskul N, Norkaew S. Knowledge, attitudes and practices regarding to malaria and Cite this article as: home environment prevention among population in Palaw township, Tanintharyi region of Myanmar. J Health Res. 2017; 31(Suppl.1): S57-63. DOI: 10.14456/jhr.2017.68

http://www.jhealthres.org J Health Res  vol.31, Supplement 1, 2017 S58

Table 1 Frequency and percentage distribution of respondents by socioeconomic and education level (N=430)

Socioeconomic and education level Frequency Percentage Age (years) 18-30 110 25.6 31-40 105 24.4 41-53 112 26.0 54-64 103 24.0 Gender Male 104 24.2 Female 326 75.8 Marital status Single 94 21.9 Married 291 67.7 Divorced 8 1.9 Widowed 37 8.6 Education Never attend school 46 10.7 Primary school 180 41.9 Secondary school 117 27.2 High school 45 10.5 College/University 42 9.8 Monthly family income(kyats) ≤150,000 156 36.3 150,001-200,000 134 31.2 200,001-250,000 53 12.3 >250,000 87 20.2 1USD = 1200 kyats (approximately) mortality. Out of estimated 54.28 million of total practices levels. population, 38.54 million populations (71%) live in at risk areas of malaria infection [3]. MATERIALS AND METHODS In Palaw Township, 89 villages were classified Study site and study population as high risk areas. 35 villages were in moderate risk; This was a cross-sectional study targeting in age and only 4 villages were in low risk areas [4]. The 18 to 64 years who stay in Palaw Township, significant reduction of malaria morbidity and Tanintharyi Region, Myanmar during June, 2016 to mortality in Myanmar is threatened by evolving July, 2016. The study was conducted in 9 villages in complexity of the problem, especially multiple Palaw Township. The estimated calculation was at resistances of the parasites to anti-malarial least 397; and 10% was added to prevent data losing. medications and the uncertainty about the financial Totally, sample size was 436 households. Study area basis to continue malaria control [5] In accordance was purposively selected 9 high malaria risk villages with experiences in Malaria, prevention is cost from 128 villages in Palaw Township. Households effective and better than cure. Regarding this, socio- were selected by proportion to size from 9 villages. cultural and economic factors, housing conditions, Sample household in each village were selected by knowledge, attitude, and practices of the community systemic random sampling method. A participant play an essential role in transmission and preventing form each sample household would be selected by malaria infection. Although there are some KAP simple random sampling method. studies regarding malaria conducted in Myanmar. No other studies were conducted in Palaw Data collection and analysis Township, Tanintharyi Region, Myanmar relating to A structured questionnaire was designed. The malaria and home environment factors. Therefore, first part of the questionnaire included socio- current study aimed to 1) determine the levels of economic and education; and the second part knowledge, attitudes, and practices regarding to included questions on knowledge, attitudes and malaria and home environment prevention and 2) practice towards malaria. Face to face interview by assess association between knowledge, attitudes and trained field workers was utilized. After data

J Health Res  vol. 31, Supplement 1, 2017 http://www.jhealthres.org S59

Table 2 Frequency and percentage distribution of respondents by related infected malaria (n=430)

Malaria infection situation of participants Frequency Percentage Malaria infected person 6 months ago No 412 95.8 Yes 18 4.2 Number of family member infected malaria No infected 284 66.0 1 person 107 24.9 More than 1 person 39 9.1 Ages of malarious persons <13 years 51 11.7 13-21 years 52 12.1 22-34 years 46 10.7 >34 years 43 10.0 collection, the questionnaire was monitored daily for Table 2 presented malaria infectious situation quality control; and the data was coded before among study participants. Only 4.2% of them had entering into the computer. malaria infected family members in the past 6 Knowledge regarding malaria was defined as months. Twenty-four percent of respondents good (greater than 80% of total score), moderate reported only one infected family member; and few (60% to 80% of total score) and poor (less than 60% of them (9.1%) had more than one in the past. of total score) according to Bloom’s cut point [6]. Majority of infected members were ranged in age Attitude and practice were classified into 3 levels between 13 -21 years old. using interval scale. Overall attitude was defined as Knowledge and practice on malaria prevention good (> 53 scores), moderate (27 – 53 scores) and For practices towards malaria prevention, poor (<27 scores). Practice levels were set as good seventy percent of participants (301 of 430 (>25 scores), moderate (13 – 25 scores) and poor participants) had moderate prevention practice level. (<13 scores). The data were analyzed with the Only 28 of them (6.5%) had good prevention statistical program Statistical Package for Social practice; and the rest of them (23.5%) had poor Sciences (SPSS version 22). Descriptive statistics practice. Table 3 showed an association between such as frequency, percentage, standard deviation, knowledge related to malaria and preventions mean and range were used for analyzing the general practice. Half of the respondents (50.7%) had poor characteristics of the respondents as well as knowledge on malaria, attitude towards malaria and knowledge regarding malaria while only 21% of practice regarding malaria prevention. Chi-square those had good knowledge. Considering on specific was used to determine the association between part of knowledge related to malaria, we found that knowledge, attitudes and practice towards malaria. most of them had poor knowledge on cause and Fisher’s exact test was performed if chi-square test symptoms of malaria. However, more than half of did not meet the assumption. them (55.6%) had good knowledge on malaria Ethical approval to conduct this study was transmission. Around 40 percent of participants had sought from Ethics Review Committee of moderate knowledge level regarding home Chulalongkorn University (COA No. 116/2016). environment prevention. Around 80 percent of good knowledge participants had moderate practice for RESULTS prevention. None of poor knowledge participants The total number of paticipants in this study was had good practice. Most of participants with good 430, age between 18-64 years. Table 1 revealed that (79.5%) and moderate (81.3%) knowledge related to socioeconomic and education level. Majority of the home prevention practice had moderate prevention respondents were aged between 41-53 years. Most of practice towards malaria. Association between them (75.8%) were female; and they had completed malaria prevention practice was strongly primary school. Around 67% of participants were significance with participants’ knowledge related to married. Thirty-six percent of them had monthly cause, transmission, symptoms and knowledge on family income less than 150,000 kyats. home prevention (p<0.01).

http://www.jhealthres.org J Health Res  vol. 31, Supplement 1, 2017 S60

Table 3 Association between knowledge on malaria cause, transmission, symptoms and preventions and practice on malaria prevention

Knowledge levels Overall practice levels Total (N=430) Good Moderate Poor p-value n(%) n(%) n(%) Overall Good 91 (21.2%) 26(11.9%) 178(81.7%) 14(6.4%) <0.001 Moderate 121 (28.1%) 2(1.7%) 87(71.9%) 32(26.4%) Poor 218 (50.7%) 0(0.0%) 36(39.6%) 55(60.4%) Cause of malaria Good 82 (19.1%) 26(9.6%) 216(80.3%) 28(10.4%) <0.001 Moderate 78 (18.1%) 2(2.6%) 53(67.9%) 23(29.5%) Poor 270 (62.8%) 0(0.0%) 32(39.0%) 50(61.0%) Transmission of malaria Good 239 (55.6%) 14(14.3%) 69(70.4%) 15(15.3%) 0.001 Moderate 93 (21.6%) 7(7.5%) 67(72.0%) 19 (20.4%) Poor 98 (22.8%) 7(2.9%) 165(69.0%) 67(28.0%) Symptoms of malaria Good 78 (18.1%) 26(10.1%) 203(78.7%) 29(11.2%) <0.001 Moderate 94 (21.9%) 2(2.1%) 58(61.7%) 34(36.2%) Poor 258 (60.0%) 0(0.0%) 40(51.3%) 38(48.7%) Prevention of malaria regarding home environment Good 108 (25.1%) 23(14.7%) 124(79.5%) 9(5.8%) <0.001 Moderate 166 (38.6%) 5(3.0%) 135(81.3%) 26(15.7%) Poor 156 (36.3%) 0(0.0%) 42(38.9%) 66(61.1%)

Table 4 Association between attitude towards malaria susceptibility, threat, treatment and home environment and practices on malaria prevention

Overall practice levels Attitude levels Total (N=430) Good Moderate Poor p-value n(%) n(%) n(%) Overall attitude Poor 59 (13.7%) 1(1.7%) 16(27.1%) 42(71.2%) <0.001 Moderate 301 (70.0%) 18(6.0%) 227(75.4%) 56(18.6%) Good 70 (16.3%) 9(12.9%) 58(82.9%) 3(4.3%) Susceptibility Poor 94 (21.9%) 5(5.3%) 55(58.5%) 34(36.2%) <0.001 Moderate 280 (65.1%) 13(4.6%) 201(71.8%) 66(23.6%) Good 56 (13.0%) 10(17.9%) 45(80.4%) 1(1.8%) Threat Poor 29 (6.7%) 1(3.4%) 10(34.5%) 18(62.1%) <0.001 Moderate 264 (61.4%) 8(3.0%) 185(70.1%) 71(26.9%) Good 137 (31.9%) 19(13.9%) 106(77.4%) 12(8.8%) Treatment Poor 52 (12.1%) 2(3.8%) 15(28.8%) 35(67.3%) <0.001 Moderate 234 (54.4%) 10(4.3%) 163(69.7%) 61(26.1%) Good 144 (33.5%) 16(11.1%) 123(85.4%) 5(3.5%) Home environment Poor 94 (21.9%) 2(2.1%) 43(45.7%) 49(52.1%) <0.001 Moderate 307 (71.4%) 21(6.8%) 234(76.2%) 52(16.9%) Good 29 (6.7%) 5(17.2%) 24(82.8%) 0(0.0%)

J Health Res  vol. 31, Supplement 1, 2017 http://www.jhealthres.org S61

Attitude and practices on malaria and home countries [9-11]. environment prevention Respondent’s attitudes toward malaria prevention Majority of the respondents (70%) had were about 13.7%, 70.0% and 16.3% who had poor, moderate attitude regarding malaria. Only 16.3% of moderate and high level respectively. Our finding them had good attitude toward overall malaria. Most found lower percentage of high attitude (40.1%) and of them had moderate attitude towards susceptibility, higher percentage of moderate attitude (58.3%) than threat, treatment and home environment. Seventy a study conducted in Karen Ethnic group in Umpiem percent of poor attitude participants had poor Mai refugee camp, Phobphra District, Tak Province practice; however, those who had good attitude [12]. This may be because negative perception of the (82.9%) were classified into moderate prevention residents who was misunderstood by local believes. practice. Focusing on specific attitude part towards We found that there was significant association malaria, most of participants who had moderate and between susceptibility, threat, treatment, home good attitude would have moderate prevention environment prevention and practices on malaria practice. But most of poor attitude led to poor prevention of respondents (p<0.001). This study prevention practice in this study. Most of revealed out some incorrect attitudes towards participants who had moderate (76.2%) and good malaria prevention. 51.5% of respondents thought (82.8%) attitude towards malaria prevention also that building house close to canal is not a risk factor had moderate prevention practice. Consequently, we of malaria. 58.7% thought that having holes in the also found a strong association between malaria house can be a greater risk of malaria infection. prevention practice participants’ attitude related to Besides, 64.9% of respondents thought that lack of malaria (p<0.01), Table 4. ceiling is not the risk factor for malaria. Hence, the program should focus on detail information of the DISCUSSION only cause of transmission by vector, anti-malarial The contribution of KAP study in high risk drug; especially, drug resistant of malaria parasite; areas of malaria infection in Palaw township of self-medication is risky as fake drugs and mosquito Myanmar has not received much attention. This proof housing structure. Accessibility to mass media study had been carried out to provide current and health education might be increased awareness understanding of malaria among this population. of malaria [13]. Regarding to malaria prevention, 70% of participants In relation to level of practice out of 430 had moderate prevention practice; while 50.7% and respondents, only 6.5% had good practice, while 16.3% of them had poor knowledge and attitude most of respondents (70.0%) had moderate practice respectively. The results showed significance regarding malaria prevention; and 23.5% had poor association between knowledge and practice and practice. This result was similar in good practice between attitude and practice (p<0.001). (8.4%), lower than in moderate practice (90.1%) Concerning to overall knowledge on malaria while higher than in poor practice (1.4%) of the prevention, 50.7% out of 430 subjects had poor study conducted in Teikkyi Township, Northeast of knowledge. This figure was lower than the finding Yangon, Myanmar [14]. According to the personal of the study which conducted in Paksong district, protection to prevent malaria, this study found that Champasack province, Lao PDR (59%) [7]. The most of respondents (67.1%) slept under net every results showed that most of respondents had poor time; 2.1% of respondents use mosquito coil at knowledge regarding causes and symptoms of night. Our finding had higher percentage of using malaria. These finding was the same as a study in bed net (51%) but lower percentage of using rural area of Ghana, which showed that people's mosquito coil (18.0%) than a study conducted in knowledge about symptoms of malaria was low [8]. Myanmar [13]. However, a Wangdi, et al. [15] Nevertheless, they had moderate knowledge suggested washing bed net every six months was a regarding home environment prevention. Improved factor associated with decreased odds of malaria housing to protect malaria is characterized by infection. features that can reduce the entry of mosquitoes On the other hand, there was very low level or indoors, such as closed eaves, screened doors and poor practice regarding mosquito repellent, windows, ceilings, metal roofs and finished or mosquito coil, and indoor and outdoor anti-mosquito improved wall surfaces. There is strong evidence spray. It showed that 3.2% always use repellent to that modern housing is protective in many tropical prevent them from mosquito bite; and the finding

http://www.jhealthres.org J Health Res  vol. 31, Supplement 1, 2017 S62 was lower than the study in Paksong District, Center. [cited 2015 June 20]. Available from: Champasack Provinince, Lao PDR (22.9%) [7]. http://www.who.int/mediacentre/factsheets/fs094/en/ Possibly, this could be an economic problem. Unlike 2. World Health Organization [WHO]. World malaria report 2014. [cited 2015 July 20] Available from: bed net, these stuffs are not freely contributed by http://www.who.int/malaria/publications/world_malaria NGOs and difficult for them to afford it. This _report_2014/en/ finding was analogous to a study done in Binh Ding 3. Ministry of Health, Myanmar, Vector Borne Disease province, Vietnam (p=0.006) [16] and a study Control. Annual report of malaria situation in Myanmar. conducted in Karen Ethnic group in Umpiem Mai Yangon: Ministry; 2005. refugee camp, Phobphra district, Tak province [12]. 4. Ministry of Health, Myanmar, Vector Borne Disease In this study, practice was statistically Control. Annual report of malaria situation in Myanmar. significant in association with knowledge and Yangon: Ministry; 2013. attitude about malaria and practices on malaria and 5. Department of Health. National strategic plan malaria home environment prevention (p< 0.01). However, control Myanmar 2010 – 2015. Yangon: Department; 2012. a previous study among women from Nigeria 6. Yimer M, Abera B, Mulu W, Belay B. Knowledge, showed that knowledge of malaria transmission and attitude and practices of high risk populations on louse- prevention were generally poor; and of that only borne relapsing fever in Bahir Dar city, north-west 36.3 % of the women associated with malaria Ethiopia. Science Journal of Public Health. 2014; 2: 15- infection from mosquito bites. [17] The higher 22. prevalence rate is more related to the practices but 7. Thanabouasy C, Pumpaibool T, Kanchanakhan N. not the knowledge [18]. Additionally, poverty Assessment of knowledge, attitude, and practice hinders the efforts of malaria control programs. regarding malaria prevention towards population in Paksong district, Champasack province, Lao PDR. Previous studies in Nigeria have shown that the level J Health Res. 2009; 23(Suppl): 11-5. of education was a strong predictor of positive 8. Agyepong IA, Manderson L. The diagnosis and malaria-related KAP [19, 20]. According to our management of fever at household level in the Greater finding, there is agreement that malaria is linked Accra Region, Ghana. Acta Trop. 1994 Dec; 58(3-4): with poverty. There is not debate about to upgrade 317-30. knowledge about malaria and provide anti-malarial 9. Vector Control Working Group. Roll back malaria supplements, get truthful understanding of housing 2015: housing and malaria consensus statement. [cited conditions to prevent malaria for effective 2015 July 20] Available from: http://www.rollback malaria.org/.../RBM%20VCWG%20Housing%20and% intervention to take place. 20Malaria%20C 10. Prüss-Üstün A, Corvalán C. Preventing disease through CONCLUSION healthy environments. Geneva: WHO; 2006. Most respondents showed poor knowledge, 11. Feo ML, Eljarrat E, Manaca MN, Dobano C, Barcelo D, moderate attitude and moderate practice regarding Sunyer J, et al. Pyrethroid use-malaria control and malaria prevention. However, there is a need to individual applications by households for other pests increase an understanding causes and symptoms of and home garden use. Environ Int. 2012 Jan; 38(1): 67- malaria among population in Palaw township, 72. doi: 10.1016/j.envint.2011.08.008 Myanmar. Providing knowledge on home 12. Harnyuttanakorn WPP, Kanchanakhan N. Assessment of knowledge, attitude, and practice regarding malaria environment improvement is a strategy to reduce prevention towards Karen ethnic group in Umpiem Mai malaria infection and transmission. It is therefore refugee camp, Phobphra district, Tal province. J Health recommended that NGOs and policy makers of the Res. 2008; 22(4): 195-8. country should encourage for malaria elimination 13. Van Herck K, Van Damme P, Castelli F, Zuckerman J, through local communities' perceptions and Nothdurft H, Dahlgren AL, et al. Knowledge, attitudes practices regarding malaria. and practices in travel-related infectious diseases: the European airport survey. J Travel Med. 2004 Jan-Feb; 11(1): 3-8. ACKNOWLEDGEMENT This study was financially supported by 14. Kyawt Kyawt S, Pearson A. Knowledge, attitudes and practices with regard to malaria control in an endemic Chulalongkorn University Graduate School Thesis rural area of Myanmar. Southeast Asian J Trop Med Grant. Public Health. 2004 Mar; 35(1): 53-62. 15. Wangdi K, Gatton ML, Kelly GC, Clements AC. REFERENCES Prevalence of asymptomatic malaria and bed net 1. World Health Organization [WHO]. Malaria Media ownership and use in Bhutan, 2013: a country

J Health Res  vol. 31, Supplement 1, 2017 http://www.jhealthres.org S63

earmarked for malaria elimination. Malar J. 2014 Sep 19. Eteng M, Mitchell S, Garba L, Ana O, Liman M, 04; 13: 352. doi: 10.1186/1475-2875-13-352 Cockcroft A, et al. Socio-economic determinants of 16. Hung DD. Malaria preventive behavior among rural ownership and use of treated bed nets in Nigeria: results villagers in Binh Ding province, Vietnam. Bangkok: from a cross-sectional study in Cross River and Bauchi Faculty of Public Health, Mahidol University; 2007. States in 2011. Malar J. 2014 Aug; 13: 316. doi: 17. Idowu OA, Mafiana CF, Sotiloye D. Traditional birth 10.1186/1475-2875-13-316 home attendance and its implications for malaria control 20. Russell CL, Sallau A, Emukah E, Graves PM, Noland during pregnancy in Nigeria. Trans R Soc Trop Med GS, Ngondi JM, et al. Determinants of Bed Net Use in Hyg. 2008 Jul; 102(7): 679-84. doi: 10.1016/j.trstmh. Southeast Nigeria following Mass Distribution of 2008.03.020 LLINs: Implications for Social Behavior Change 18. Dawaki S, Al-Mekhlafi HM, Ithoi I, Ibrahim J, Atroosh Interventions. PLoS One. 2015; 10(10): e0139447. doi: WM, Abdulsalam AM, et al. Is Nigeria winning the 10.1371/journal.pone.0139447 battle against malaria? Prevalence, risk factors and KAP assessment among Hausa communities in Kano State. Malar J. 2016 Jul; 15: 351. doi: 10.1186/s12936-016- 1394-3

http://www.jhealthres.org J Health Res  vol. 31, Supplement 1, 2017